2014
LIV Acupuncture considers it an integral part of our therapeutic process for every individual seeking our care
and treatment to be completely involved in the decision making process in regards to their healthcare.
IT IS THE RESPONSIBILITY OF LIV ACUPUNCTURE AND ITS AGENTS TO OFFER BOTH INITIAL AND ONGOING
PATIENT EDUCATION AS TO THE DIAGNOSTIC PROCEDURES USED, THE NATURE OF TREATMENTS OFFERED,
MATERIALS AND EQUIPMENT USED, EXPECTED TREATMENT OUTCOMES, PROPOSED TREATMENT PLANS, RISKS
AND BENEFITS OF ALL PROCEDURES AND AVAILABLE ALTERNATIVE TREATMENT OPTIONS.
Success in our therapy and philosophy is dependent on an open and trusting Patient – Practitioner relationship with
communication and safety as equal primary goals. You, the patient, should feel informed and in control of any therapeutic options
proposed for the treatment of your health condition and you have the right, at any time, to further inquire about any treatment,
halt or decline any treatment methods, and elect therapeutic options you prefer as offered by LIV Acupuncture center and its
agents. We, at LIV, will protect and support your right to all information pertinent to your informed decision making process
regarding all procedures offered at our center. We consider our role in your healthcare to be both Educator and Practitioner.
Procedures Commonly Used at LIV Acupuncture
Acupuncture/Moxibustion: I understand that acupuncture is performed by the insertion of sterile, single-use needles through the
skin at certain points on or near the surface of the body in an attempt to treat bodily dysfunction or diseases, to modify or prevent pain
perception, and to normalize the body’s physiological functions. I am aware that certain adverse side effects may result. These could
include, but are not limited to: local bruising, minor bleeding, fainting, pain or discomfort, and the possible aggravation of symptoms
existing prior to acupuncture treatment and, in rare instances, nerve damage and organ puncture.
Direct Moxibustion: I understand that if I receive direct moxibustion as part of therapy, there is a risk of burning or scarring from its
use as this therapy involves the burning of a particular herbal material, in a variety of possible forms, very near the skin surface.
Acupressure/Tui-Na Massage: I understand that I may also be given acupressure/tui-na massage as part of my treatment to modify
or prevent pain perception and to normalize the body’s physiological functions. I am aware that certain adverse side effects may result
from this treatment including, but not limited to: bruising, sore muscles or aches, and the possible aggravation of symptoms existing prior
to treatment.
Electro-Acupuncture: I understand that I may be asked to have electro-acupuncture administered with an acupuncture treatment to
provide local stimulus on a set of needles via mild voltage (approx. 0.6miliamperes). I am aware that certain adverse side effects may result
including, but not limited to, accidental electrical shock, pain or discomfort, and the possible aggravation of symptoms existing prior to
treatment.
Cupping: I understand that the practice of Cupping involves a glass cup(s) being applied to the skin through the pressure in the cup
being reduced by using change in heat or by suction, so that the skin and superficial muscle layer is drawn into and held in the cup. In
some cases, the cup may be moved while the suction of skin is active, causing a regional pulling of the skin and muscle. It has been
explained to me that this procedure involves the burning of material in the cup, near the skin and that burn is a potential risk. I also
understand that bruising is both expected and common with this therapy.
TDP Lamp: I understand that a TDP Lamp is a medical device which features a round plate coated with a proprietary mineral clay
formation consisting of 33 earth elements and emits an infra-red wave, upon being heated, considered therapeutic to the body. I
understand that if the lamp were to fall over due to an accidental knock or some breach in structural integrity that this would result in a
serious burn.
My Consent to Treatment by a Licensed Acupuncturist at LIV Acupuncture is given voluntarily, without coercion, and may be withdrawn at
my discretion. I have carefully read this form and I acknowledge its full contents to be reflective of any conversation, communication, and
literature provided to me by a Licensed Practitioner employed at this facility. I understand that I may refuse any treatment and that my comfort
is a priority. I understand that I may ask my Practitioner for more information at any time.
By signing this form, I X_______________________________________________ agree that ______________________________________ (Acupuncturist) has disclosed to
me sufficient information enabling me to knowledgeably consent to treatment at LIV Acupuncture Center. Date _______/_____/______.
While at LIV Acupuncture and/or while voluntarily under our care as a respected Patient you consent to disclose the following upon your
earliest knowledge; 1. If you are planning to or become Pregnant 2. Any side effects experienced or Adverse reactions to treatment
3. Any changes in Medications prescribed by a Physician or otherwise 4. A change in status of any Bleeding disorder or new
Pacemaker/Medical implants device use. _ X ___________________________________________________________ (Patient) Date _______/______/______ .
IMPORTANCE OF CONSULTING A PHYSICIAN
WE, THE UNDERSIGNED, DO HEREBY AFFIRM THAT (THE PATIENT) HAS BEEN ADVISED BY A LICENSED ACUPUNCTURIST AT OUR
FACILITY, TO CONSULT A PHYSICAN REGARDING THE CONDITION OR CONDITIONS FOR WHICH THE PATIENT SEEKS ACUPUNCTURE
TREATMENT.
_X________________________________ PATIENT SIGNATURE _______/_______/______DATE
___________________________________CLINICIAN SIGNATURE ______/_______/_______DATE